case of the week

1. A 27 year old construction worker fell 3 metres and struck heavily
on his left flank, landing across some scaffolding. He is complaining
of left sided abdominal and back pain and a catheter urine specimen
shows macroscopic blood. His pulse is 100, BP 95/70 and his
conscious state is normal. Clinically there seem to be no injuries
other than those to his abdomen.
•Describe and interpret the CT scan images
•What treatment does he require?

3. The CT shows a high grade injury to the left kidney. The normal architecture of the
kidney is shattered, there is extensive haematoma, and contrast extravasation
suggesting active bleeding. Renal injuries are graded one to five according to their
anatomic severity; from minor haematomas, through deeper lacerations to complete
renal fractures and avulsion of the renal hilum. This is a Grade 5 injury. The degree
of expected blood loss is confirmed by his haemodynamic readings which suggest
compensated hypovolaemic shock.
Although there is an increasing trend towards conservative management of higher
grade injuries to vascular organs such as the liver, spleen and kidneys this patient
has a very high chance of requiring a nephrectomy and needs an urgent surgical
referral with that in mind. In the ED remain aware of the possibility of other injuries
given the significant fall mechanism but the focus should be on “controlled
hypotensive” resuscitation. This means sufficient volume to maintain perfusion to
vital organs such as the brain, heart and (his normal) kidney however it does not
require a return to “normal” blood pressure levels. His current mean arterial pressure
is more than adequate. Overvigorous fluid resuscitation will worsen further bleeding
and later coagulopathy. Should substantial volumes of blood be required then use a
“massive transfusion” protocol.